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What Happens At My 16 Week Visit?

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With the bulk of the laboratory testing, physical exam and an established due date from your first pregnany visit, your 16 week visit is all about routine obstetric care. Routine care for the rest of the pregnancy centers on prevention, assessment and education.

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Overwhelmed by all the information about pregnancy? Looking for a checklist to guide to each pregnancy visit? Don’t expect your birth provider to do all the work.

Take control of your care and get The Too Good to Be True Pregnancy Guides to guide each step of your pregnancy care.

These guides were made to go along with each of your visits with your provider and to make sure you are getting the most up to date, evidence-based care for you and your baby.

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What are the components of the 14-16 week visit?

  • Overall assessment of woman and her baby
  • A review of symptoms or patient concerns with attention/intervention to each concern as appropriate
  • A screening (if indicated, often for depression/anxiety or intimate partner violence)
  • A brief physical exam
  • A review of an ultrasound report, laboratory/genetic screening results, or other results
  • Pertinent education
  • Reassurance
  • A review of warning signs and recommended follow up (American Academy of Pediatrics [AAP], & American College of Obstetricians and Gynecologists [ACOG], 2017); King et al., 2015)

Let’s break it down!

Review of symptoms or patient concerns

These are any symptoms that have occurred since the last visit with the provider that the patient desires to discuss with the provider. An example is: “I think I have a yeast infection because there are white chunks coming out of my vagina and it itches.” Or, “I had a yeast infection two weeks ago but I used Monistat over the counter and my symptoms disappeared. Was this okay to do?”

Common questions for this visit include…

  • I haven’t felt my baby move yet. Is that normal?
  • Is it okay to have sex?
  • How much caffeine can I have each day?
  • Should I be working full time?
  • Can I travel while pregnant? Can I get on an airplane? When is a good time to travel?
  • Can I go running or to spin class?
  • Can I take a bath?
  • Can I get in a hot tub?
  • Can I eat sushi?
  • Should my partner change the litter box?
  • Is it okay that I am taking a nap every day?
  • I’m not sleeping well – what can I do to sleep better?
  • When am I going to find out the gender?
  • Can I take gummy prenatal vitamins?
  • Can I get my hair done? My nails too?
  • What can I do about round ligament pain?
  • Why don’t I have to pee in a cup every visit?
  • What kind of foods should I be eating to prevent anemia?
  • Should I use a doula?

Most of these questions tell your provider that you’re feeling a little better than the last visit to the clinic and that you have had a return of energy and less fatigue, nausea and vomiting.

Because it’s a routine visit, the review of system questions are targeted to pregnancy unless the woman’s history or questions indicate investigation and follow up.

These questions are generally the same at every visit for the rest of pregnancy. The questions are:

  • Are you feeling your baby move?
  • Are you having any vaginal bleeding, leaking of fluid, abdominal pain or contractions?
  • Have you had any visits to the emergency room since your last visit? (AAP & ACOG, 2017)

After the routine questions, I have some favorite questions that I like to ask during this visit. A lot of these questions are centered around a return to energy (although fatigue and extra naps are still very normal), return to normal appetite, and changes in sleep habits or patterns. I also like to review weight gain, nutrition and exercise.

These are some of the questions I ask at the 16 week visit:

  • Has your energy returned?
  • Tell me how you are sleeping at night?
  • What kind of exercise are you doing?
  • Has your appetite returned? Do you have any aversions?
  • Do you have any back or pelvic pain?
  • What do you know about breastfeeding?
  • What are your plans for education about pregnancy and childbirth?

The Screening

Screenings are usually completed in a number of fashions – sometimes by the tech asking the woman questions or by having the woman fill out a piece of paper.

Screening for psychosocial factors is an important part of prenatal care. Some risk factors (i.e. homelessness, loss of job, smoking, drinking, moving…) are present before prenatal care and some factors happen during the pregnancy or postpartum. To increase the number of opportunities to provide timely intervention, support or referral, ACOG & AAP (2017) recommend screening on a regular basis during prenatal care and documentation of each screening in the prenatal record.

If the woman has a history of depression or anxiety, reports new symptoms of either depression or anxiety, or is on medication for mood management, a screening is appropriate to assess her mood and risk. ACOG (2015) only recommends screening once during the perinatal period and once a the postpartum period.

Screening tools vary across practices and regions of the world. In the United States, the most common tools used for screening in pregnancy at the EPDS or the PHQ (PHQ-2 or PHQ-9).

It is always appropriate to ask that the provider review your screening results with you. A screening tool is very valuable. And sometimes a woman may feel uncomfortable talking about her mood even though she knows something isn’t feeling quite right. A positive screening is a flag for your provider to ask more questions and also review options for support, counseling or resources.

The Exam, Lab Testing, and Ultrasounds

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Exam

The exam is limited to checking for normal progression of the pregnancy.

  • Vital signs (weight, blood pressure, pulse)
    • Weight is an indicator of many things. It can tell your provider how severe your nausea or vomiting is, or, how often you eat fast food. Weight gain recommendations are based on BMI and most weight gain up to 16 weeks is an increase in blood volume and breast growth.
    • Blood pressure is another indicator of health in pregnancy. Typically, your blood pressure is the highest at your very first pregnancy visit and then the lowest in the second trimester.
    • Temperature is checked depending on the practice you work in.
    • Your pulse or heart rate increases in pregnancy about 10 to 15 beats per minute to accommodate all the extra blood volume in your body. You may notice that your resting heart is the same as when you are not pregnant, or that it has slightly increased.
  • Fundal height (the location of the top of your uterus as palpated by the provider in relation to either you pubic symphysis or your umbilicus)
    • The height of your uterus tells the provider is the pregnancy is growing normally. A uterus that is higher in the abdomen than expected could be a twin gestation, a full bladder, and just the habitus of a woman. At 16 weeks, your uterus is usually between your pubic bone and your belly button. Your provider will palpate gently with their fingers to feel where the top of your uterus is in your abdomen. Typically, the fundal height is not measured with a measuring tape until 20 weeks.
  • Auscultation (listening) to the baby’s heart rate
    • The most exciting part of the visit! Most providers use a handheld doppler to measure to the baby’s heart rate but the heart rate can also be assessed by ultrasound machines. Normal fetal heart rates are between 110-160 beats per minute and heart rates are higher at the beginning of pregnancy.
Ultrasound

Most 16 week visits do not include an ultrasound.

Ultrasounds “should be performed only when indicated and should be appropriately documented” (AAP & ACOG, 2017, p.176). Some obstetric providers perform an ultrasound at every prenatal visit. This is not the standard of care and is done for billing purposes (i.e. the provider can bill and code for more money if they perform an ultrasound at your visit).

Occasionally, it is difficult to find fetal heart tones with a doppler; in these cases, a limited ultrasound is done to confirm the fetal heart rate.

Laboratory testing

The MSAFP for Neural Tube Defect Screenings

  • The most common blood test offered between 15 to 21 weeks if the maternal serum alpha-fetoprotein (MSAFP) screening. The screening looks for a high level in the pregnant women’s blood of a pregnancy hormone called the MSAFP. This hormone occurs in the pregnant woman’s blood at a higher amount when there is a neural tube that is not formed right in the baby.
  • 1 to 2 out of 1,000 births has a neural tube defects (NTD). NTDs occur when the brain and spinal cord do not form correctly in the baby.
  • NTDs can be open or closed, but 90% of defects are open NTDs. When the neural tube is open, there is a higher level of a protein called alpha-fetoprotein (AFP) in the maternal blood stream than normal.
  • By testing a pregnant person’s blood for this protein, we can screen to see if the baby is at high or low risk for an open NTD.
  • The best time for an AFP screen is 16 to 18 weeks of pregnancy.
  • Abnormal screenings require follow up, ultrasounds and more testing (Diagnostics Products Association [DPC], 2001).

Lab testing at 16 weeks consists of catching up any outstanding labs from the initial OB visit and any pertinent genetic (carrier or aneuploidy) screening. Screenings vary greatly across the United States and the area of the country you live in. Insurance providers also vary. Ask your provider about the screening options they offer.

The Education

The is so much education to offer at 16 weeks. Most women have had a great return in energy and aren’t so tired. There is also a peak in eagerness to learn about the pregnancy and the interventions for the common discomforts of pregnancy. These are the common areas of education, but the sky really is the limit and varies greatly from provider to provider.

Constipation
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The first trimester is wrought with constipation because the hormone progesterone slows down the activity of the bowels. Well really, progesterone slows down everything – you are growing a baby!

There are a lot of things you can do to manage constipation but learning about what causes constipation and how to incorporate some lifestyle changes can really make the difference in your bathroom time and help prevent hemorrhoids. One of the best handouts I’ve seen on constipation is from the American Urogynecologic Society.

The basics are this:

  • You need to drink enough water to prevent hard stools and provide your body with what it needs to function. The amount of water you need to drink is half your body weight in ounces. Example: You weigh 160 pounds. You need to drink about 80 ounces of waster each day during pregnancy.
  • You have to encourage your bowels to move if you want the poop to come out. The easiest ways to get your bowels moving are to go on a 20-30minute walk each day, eat a high fiber diet or use fiber supplements (try pitted dates or dried prunes for a natural bowel stimulant).
  • Daily herbal teas can help bowel health and digestion – try peppermint, chamomile, ginger or lemon flavors or leaves for the biggest bowel benefits.
  • Treat your pelvic floor right in the bathroom. Use a large stack of books or a toilet stool to rest your feet/heels on during pooping to make pooping easier for your pelvic floor – this can also help reduce hemorrhoids! Bonus: You will love a toilet stool for support during your postpartum recovery when it feels like your whole bottom might fall in the toilet.
  • You may need to adjust from week to week or trimester to trimester depending on how you feel and what your body is doing.
Toilet Stool

Read more about poop and pregnancy: Pooping During Pregnancy: Constipation, The Runs, Hemorrhoids and Everything You Would Rather Google Instead Of Ask Your Provider.

Exercise

During pregnancy, and in the absence of a complication or guidance to exercise, ACOG & AAP (2017) recommend 30 minutes of moderate exercise most or all days during pregnancy.

Exercise does not have to be fancy. A simple 20 minute walk every day is all you need. A little bit of exercise will help you sleep better, poop better and it will help your joints, bones and ligaments respond to the normal aches of your growing uterus.

Strength training is okay to continue during pregnancy, and heck, it’s encouraged. Building and maintaining strong muscle during your pregnancy will help you stay strong through the normal aches of pregnancy, have a shorter labor and pushing stage during birth, and recover quicker during the postpartum phase. Most women are able to use 10 pound weights without difficulty. Women that have been strength training before pregnancy can generally continue what they were lifting before. For example, a woman who was squatting using two 20-pound weights is good to continue lifting those same weights during her pregnancy.

While strength training, do watch out for these warnings signs:

  • You should not feel like you need to hold your breath to complete exercises. If you feel like you are holding your breath, you need to decrease your weight that you are lifting, alter the exercise to accommodate your weeks of pregnancy, or stop doing that particular exercise.
  • You should not feel extra pressure in your vagina or pelvis while you are exercising – this can be a sign of a weak pelvic floor and can cause prolapse of your pelvic organs. If you think/know you have some prolapse, please start pelvic floor physical thearpy during your pregnancy. It is absolutely possible to help strengthen your pelvic floor while you are pregnant.
  • You should be able to carry on a conversation through any activity you are participating in. If you are working so hard that you can’t talk to someone, you are probably working out too hard!

Exercise is so important that it’s one of the main interventions implemented in women who are diagnosed with gestational diabetes in pregnancy. Women with gestational diabetes are encouraged to go for a 10-15 minute walk after eating because while you are walking your body doesn’t need insulin for the glucose from your food to get inot the cells!One of the best times to go for a brisk walk is right after you eat a meal. If you are walking after mealtime, your body doesn’t need insulin to get glucose into your cells!

The only guidance ACOG & AAP offer regarding exercise is to avoid exercise with a high risk of falling or abdominal trauma – think snow/water skiing, skydiving, and horseback riding (2017). Each exercise program should be weighed for risk factors. Scuba diving is also not recommended during pregnancy.

The following warning signs are reasons to stop exercise:

  • Chest pain
  • Vaginal bleeding
  • Dizziness
  • Headache
  • Decreased fetal movement
  • Amniotic fluid leaking
  • Muscle weakness
  • Calf pain or swelling
  • Regular uterine contractions (AAP & ACOG, 2017)

I really like for woman to set goals for exercise during pregnancy. It’s a really long period of time to set up some good habits for after the baby arrives. I had one patient that made a goal to do 100 spin classes before her due date! She totally did it!

Fetal Movement

Most women feel the first little kicks of their baby (or babies) around 16 to 18 weeks. Fetal movement is a sign of fetal wellbeing. Movement varies from trimester to trimester. It is normal not to feel the first movements for up to 20 weeks – especially if there is an anterior placenta. But once you start to feel the baby move, expect to feel movement in that same pattern for the days afterwards.

Learn about why monitoring your baby’s movement is important at Count The Kicks. (They have a great app too that you can download for free!)

The Royal College of Obstetricians & Gynaecologists has one of the best handouts I’ve seen! In short, it’s good to review when a mama is going to first feel her baby move and what she should expect in the days and weeks to follow!

Round ligament pain
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Most women have had some round ligament pain by their 16 week visit, but many don’t that is what their pain was or what caused it. The pain is usually felt when the mama moves from sitting to standing quickly, rolls from one side to the other in bed, or has a puppy or other small child pounce on their lower belly.

The pain comes from the insertion points of the round ligament. The ligaments work to hold the uterus steady but there are always some movements of the uterus from side to side or front to back. Movement that trigger the sharp pain felt as ’round ligament pain’ are when the ligament or ligaments are strained or stretched too quickly.

Try these tips to manage your pain:

  • Change position slowly whether you are rolling from side to side in bed or moving from standing to sitting. When rolling over in bed, try to keep your knees together to support the pelvis and move your hips slowly.
  • Use a pregnancy support belt to support the ligaments during your work or daytime activities. Don’t wear the belt at night time. (This was the belt I used for all 4 of my pregnancies, including working my 24 hour shifts as a midwife. I continue to recommend this belt or a similar one over and over during triage visits!)

  • For sore ligaments (usually from a long day at work, hiking or shopping), try a heated rice sock or heating pad. Or better yet, try atching routines online warm to hot bath with epsom salt to soothe those sore bits.
  • Try stretching or yoga before bed – simply search for pregnant stretching routines online and pick one that you like from the various options.
  • If you are miserable and are not getting relief from round ligament pain, ask for a referral to a physical therapist in your community to work on stretches, support belts and exercise specific to your pregnancy.

Some good handouts for round ligament pain are here and here.

Weight gain and Nutrition

Weight is a vital sign. A provider should address a woman’s weight gain at every visit and give guidance and reassurance about her weight in relation to the guidelines below. This is an area where providers have a lot of room to improve. Most clinics have a nurse complete the prenatal education for a patient and then the woman doesn’t hear about her weight for the rest of her pregnancy.

Women can track their weight at home in between prenatal visits with a simple scale purchased from any store.

But if tracking your weight causes you stress or anxiety, it’s okay to bypass a scale at home. For women with a history of an eating disorder, consider stepping on the scale backwards so you can’t see the number. Ask your provider to twlll you how you are doing in general terms: “Your weight gain is great!” or “Let’s discuss your nutrition a little more today.”

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Closely tied to weight gain is nutrition. The 2020-2025 dietary guidelines for pregnant and lactating women offer a nice chart for guidance on what to eat and how much.

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The guidelines also offer a nice chart on on the differences in calorie intake from trimester to trimester and also for lactation. The differences in lactation calories are important to note. The first 6 months have a lower calorie intake than the second 6 months to encourage loss of pregnancy weight. Return to pregnancy weight should be gradual and this table should be used as a guide.

Note that 330-400 extra calories are needed throughout breastfeeding!

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The Follow Up

Whew, we made it through all that information…but where do you go from here? The follow up information is just as important as the rest of the visit!

Here’s a list to review with a woman and her family before leaving the clinic!

  • When is the next recommended appointment? (Usually it’s a 20 week visit and another appointment for you anatomy ultrasound)
  • Are any referrals needed?
    • Genetic counselor
    • Maternal fetal medicine
    • Physical therapy
    • Chiropractor
    • Mental health counseling
    • Social work
    • Nutritionist (vegan, vegetarian, underweight/overweight BMIs, multiple gestation)
    • Lactation consultant (prior breast surgery or breastfeeding concerns)
  • Are any medical records needed?
    • Encourage patient to request records as indicated
  • Review upcoming laboratory testing
  • Review upcoming ultrasounds
  • Review need to pick up medications OTC or prescriptions
  • Enroll in group prenatal care
  • Are there any last questions or concerns?

Other goodies…

For providers and women. the Share with Women Handouts cannot be beat for many discomforts and conditions of pregnancy.

ACOG’s Resources for You (Frequently Asked Questions about pregnancy/women’s health) and Healthychildren.org‘s Prenatal Resources are also excellent resources.

For any recommendations about books to read during pregnancy or breastfeeding, a full list is available for free on the BOOKS & MORE page!

These are some great online childbirth resources to recommend for the mama starting to look at education about labor and birth.

These are some great podcast recommendations for pregnancy and parenting.

Whew! That’s a wrap. Remember, this is only a guide for the 16 week visit. Providers and patients work together to address the needs at the time of the visit. And, much of prenatal education is reviewed again and again!

Overwhelmed by all the information about pregnancy? Looking for a checklist to guide to each pregnancy visit? Don’t expect your OB provider to do all the work – take control of your care and get The Too Good To Be True Pregnancy Guides to guide each step of your pregnancy care.

Maximize the value of your pregnancy care with these guides now.

References

American Academy of Pediatrics, & American College of Obstetricians and Gynecologists. (2017). Guidelines for perinatal care (8th ed.). DOI 10.1002/14651858.CD003519.pub3

American College of Obstetricians and Gynecologists. (2018). Screening for perinatal depression. Commitee opinion 757. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/11/screening-for-perinatal-depression

Diagnostics Products Association. (2001). Patient brochure for alpha-fetoprotein (AFP) testing. https://www.accessdata.fda.gov/cdrh_docs/pdf/P010007d.pdf

King, T., Brucker, M., Kriebs, J., Fahey, J., Gegor, C., & Varney, H. (2015). Varney’s midwifery (5th ed.). Burlington, Massachusetts: Jones & Bartlett Learning.